Tropical diseases occur mainly in tropical and subtropical climates. They can be caused by viruses, bacteria, fungi and especially parasites and can more easily attack people who use it immunosuppressive drugs against rheumatic diseases. The diseases can break out among travellers, and they are increasingly also "imported" with travelers from distant regions. The symptoms can sometimes be confused with rheumatic inflammations such as connective tissue disorders in the form of Systemic lupus erythematosus (SLE), Sjögren's disease, Rheumatoid arthritis, Spondyloarthritis and systemic Vasculitis (differential diagnoses).
Symptoms
Tropical diseases have different symptoms, but varying fever, rashes or nodules under the skin, abdominal pain, joint and muscle pain are not unusual.
Examinations
Medical history surveys foreign travel, especially stays in tropical and sub-tropical regions, as well as current symptoms (see above).
Clinical skin, joints, lymph nodes and internal organs such as the liver and spleen are examined. The eyes and mouth are also inspected.
Blood and urine samples may show signs of inflammation with high CRP and SR, low blood cell counts, elevated liver enzymes or signs of impaired kidney function. A urine test reveals whether kidney inflammation is present. Special tests are taken according to suspicion and need.
Imaging of the lungs, internal organs and brain is done in case of relevant symptoms.
Other investigations may include samples from faeces and spinal puncture with assessment of spinal fluid from the nervous system. Tissue samples from the affected area in some cases.
Treatment
Bacterial and parasitic infections are often treated with antibiotics, while viruses and others receive measures against symptoms and possible complications. Please see more under the individual diseases below.
Literature
Below is information on some current tropical diseases:
Bilharziosis (Schistosomiasis)
Most cases in Africa. Intestinal infection with a parasite (chronic abdominal pain and indigestion). Urine infection (haematuria). Chronic course with some fever and anemia. May cause chronic back and head pain. Diagnostics by MRI (localized inflammation) and Serum Schistoma IF antigen, ELISA Egg titer, Serum Schistoma IF. Joint inflammation (arthritis) is described (reference: Rakotomala HN, 2017). Granulomatous inflammation.
Definition. Tropical disease caused by parasites. There are several types of schistosoma parasites. Most often, a chronic condition develops. The parasites attack the skin, bladder and intestines, but can also cause arthritis (arthritis). Eggs left in tissue cause a granulomatous inflammation.
Disease Causes. 1-2 cm long worms (Termatoder). Bladder carharzinosis: S. haematobium. Skin infection when bathing in infected lakes. Intestinal bilharzidosis: S. mansoni, S. japonicum, S. intercalaticum, S. mekongi.
Occurrence. Tropics, subtropics. Over 85% are infected in Africa south of the Sahara. Asylum seekers from Africa. Less common in the Caribbean, South America, the Middle East and Asia.
Contamination. Transmitted via contaminated bathing water. The parasites originate from infected freshwater snails. Children in particular (who play in water) become infected.
Incubation. 2-7 weeks to first symptoms (itchy skin on feet and other parts that have been exposed to contaminated fresh water). 4-12 weeks to symptoms from internal organs
Symptoms. Initially. Itchy little nodules in the skin (especially on the feet) that have been in contact with contaminated fresh water, hives (urticaria). Later. Fever, abdominal pain (intestinal infection). May cause chronic back and head pain, diarrhea (bloody), exhaustion, cough (lungs), genital mucosal bleeding (in genital manifestation), blood in urine (bladder affection).
Rheumatic symptoms: Arthritis (arthritis) is described (reference: Rakotomala HN, 2017).
Investigations of blood and urine. Extreme eosinophilia in blood (by differential count of white blood cells). Effective screening of parasite antigen with ELISA test of blood. Serum Schistoma IF antigen, ELISA egg titer, serum Schistoma IF. Antibody can be detected in a blood test. Microscopic examination of parasite eggs in faeces (possibly also in urine). A tissue sample from the rectal mucosa (or urinary bladder) can detect eggs if they have not been detected by microscopy. Bladder: Hematuria (blood in urine).
Complications . Increased risk of bladder, colon and liver cancer in the long term. Portal hypertension. Focal epilepsy (neuroschistosomiasis) in S. japonicum.
Diagnosis. Tropic history + detection in urine, faeces or tissues. Antibody detection. Antibody is specific (>95%), but persists for up to several years after the infection has been treated and overcome.
Treatment. Praziquantel (Biltricide) (a single dose annually). More than 80% recover.
Prevention/prophylaxis. Prohibition on swimming in infected lakes. Avoid infected drinking water. A vaccine is being tested.
NOTE! Harmless bilharzia species cause bath dermatitis in Central Europe and North America (reference: Omar HN, 2016)
Literature: Al Amin ASM, 2022, Hinz R, 2017, Kristiansen T, 2021
Chikungunyai
Asia, Africa, Central and South America. Virus infection. Fever, rash, strong joint pain (fever, rash and severe joint pain) (reference: Runowska M, 2018)
Definition. Viral disease caused by Chikungunya. Increasing number of infected people in Western countries as of 2014.
Contamination.. Like wood dengue fever the disease is transmitted via mosquitoes (aedes mosquitoes).
Occurrence. Epidemics in West Africa, East-Central, South African countries and Asia. In recent years also in the Caribbean and the USA (few cases).
Symptoms. After a mosquito bite, a high fever (up to 40 degrees Celsius) begins 2-3 days after infection (maximum after 12 days). Small-dotted (petechiae) or spotted (maculopapular) rash on the body and occasionally also on the arms and legs. Rheumatic symptoms are common. Powerful Pain in multiple joints (Arthralgia) that can also swell (Arthritis). In many cases, the legs swell. Symptoms may also include headache, nausea, vomiting and eye symptoms photophobia. Some get too Eye infections (iridocyclite).
Rheumatic symptoms. Powerful joint pain (fever, rash and severe joint pain), arthritis. (reference: Runowska M, 2018)
Diagnosis. PCR tests of blood can detect infection within a few days. Serological tests for chikungunya virus IgM antibody are available, but "false positive results" may occur. Virus culture after a blood test is possible, but the examinations take at least 1-2 weeks.
Differential diagnosis. Dengue Fever
Prevention. Mosquito protection. No vaccine is available (as of 2015), but is being tested.
Treatment. No specific treatment. Symptom treatment for pain with NSAIDs such as naproxen or paracetamol is applicable.
Progress / Forecast. The fever disappears suddenly, usually after two days, but joint pain, headache and fatigue often last a week or longer. Most people become completely symptom-free within a couple of months (younger people recover the fastest). Chronic disease in the form of persistent pain has been reported.
Literature. Rodriguez JAO, 2022, Tanaya A, 2017, Runowska M, 2018; Silva Jr JVJ, 2018.
Dengue fever (Break-bone fever)
Asia, Southern part of Africa, Central and South America, virus, fever, headache, muscle and joint pain, eczema (measles-like)
Dengue Fever: Licensed under Public Domain via Commons - https://commons.wikimedia.org/wiki/File:Dengue06.png#/media/File:Dengue06.png
Definition. Dengue fever is a tropical disease caused by dengue virus (ARBO virus, a flavivirus). Rheumatic pain ("breakbone fever") can be part of the disease picture
Contamination. Transmitted via mosquitoes. Four types.
Occurrence. Dengue fever is a frequent cause of child mortality in Asia, especially Thailand and South America, is also found in the Caribbean (Cuba) and the southern United States. Increased sharply since the 1960s: Between 50 and 528 million are infected annually. Most frequent viral infection that tourists import from the tropics.
Incubation time (from infection to symptom). From infection to symptoms: 2 – 10 days
Symptoms.
Over 90% are without symptoms or as flu-like for approx. one week. Less than 10% get a high fever: 1st stage; 1-2 days of high fever, sweating, redness of the face. Severe rheumatic joint pain in the spine, arms and legs ("breakbone fever"). Bradycardia (slow pulse). Headache mostly behind the eyes, sore throat, fatigue. Bitter metallic taste in the mouth. Viral Myositis may occur. 2st stage (after 4-5 days) with fever again. Measles-like rash, lymph nodes swell. 3st stage after 5-6 days, recovery occurs which lasts for several months. Some people experience long-term (several months) laxity and temporary hair loss. Second-time infection occurs, for example, in previously infected immigrants who have been at home on holiday. Fever first days. When the fever recedes, skin bleeding and severe stomach bleeding occur.
Rheumatic symptoms. Severe joint pain in the spine, arms and legs ("breakbone fever").
Complications . Children in particular can get super-infection with different dengue virus species. 2% bleed with too low a platelet count. Meningoencephalitis (inflammation of the brain). Transient visual disturbances due to eye disease (retina).
Differential Diagnoses / Similar Diseases: Chikungunya in South East Asia, Ebola, Hanta virus, Malaria, Ross River Virus in Australia, Typhus abdominalis, West Nile Virus in Israel/Egypt.
Diagnosis based on medical history with symptoms (see above) and examination findings. Blood tests: Mild leukopenia (low white blood cell count), relative lymphocytosis (increased number of a type of white blood cell), thrombocytopenia (low platelet count), transaminases (liver enzymes), viral RNA, antibody, rapid tests. Stasis test: Blood pressure cuff clamps around the upper arm for 2 minutes (pumped up to between systolic and diastolic blood pressure): Many small hemorrhages (petechiae) below the cuff (more than 10 petechiae per square inch).
Treatment. Symptomatic, fluids intravenously. Blood transfusion in severe cases. Not acetylsalicylic acid (ASA) because of bleeding risk.
Prognosis. Good life expectancy at first infection. Immunity lasts for a few months and no cross-immunity to other species. The next infection is more serious. About 20% mortality if untreated. Children have the worst prognosis.
Prevention. Avoid mosquitoes, Air conditioning. As of 2020, a vaccine (Dengvaxia CYD-TDV) is available, but a better vaccine that provides a higher degree of protection (98%) will soon be on the market.
Literature. Schaefer TJ, 2022, Sharp TM, 2017, German Shepherd TJ, 2019
Ebola
West and Central Africa, virus, fever, sore throat, headache, joint and muscle pain in the acute phase of the disease and as a chronic manifestation (reference: Amissah-Arthur MB, 2018), vomiting, diarrhoea, bleeding and multi-organ failure.
Definition. Viral infection caused by Ebola virus. Serious course of illness. Rheumatic symptoms can be part of the disease picture.
Contamination. Epidemics in West Africa. Transmitted between people via direct contact, blood or other body fluids.
Symptoms. Flu-like (but usually not sore throat or chest pain), fatigue, fever, headache, joint and muscle pain, abdominal pain, sudden onset, vomiting and diarrhoea. Some get a rash. The symptoms usually appear 8-10 days after infection (incubation period). Bleeding from mucous membranes (gastrointestinal tract, nose, gums, vagina) occurs after 5-7 days from the onset of symptoms in 40-50%. Bleeding is a serious symptom that worsens the prognosis.
Rheumatic symptoms. Joint and muscle pain in the acute phase of the disease and as a chronic manifestation (reference: Amissah-Arthur MB, 2018).
Diagnosis. Travel history. Antibody tests (ELISA) and PCR most relevant. Virus detection also possible, but takes longer. Electron microscopy can recognize viruses, but not the specific type.
Treatment. The treatment is to give fluids, painkillers and fever-reducing treatment in the isolation/intensive care unit (in Western countries).
Vaccine. A vaccine against Ebola has been developed.
Prognosis. If recovery does not occur, multi-organ failure and death occur. Debilitated people (old age, HIV, other illness) are most at risk. Mortality is more than 50%.
Differential diagnosis: Malaria, Dengue fever, Other tropical diseases
Literature: Amissah-Arthur MB, 2018)
giardiasis
Contamination. Parasite Via water. Most are infected during their stay in Asia, but it also occurs in Norway. Most people become infected from other people or through contaminated drinking water and food. Giardiasis can also be transmitted sexually.
Symptoms. Acute gastrointestinal infection. People with rheumatic disease and immunosuppressive drugs may be more susceptible. In some, more chronic symptoms occur, with periodic diarrhoea, flatulence, malabsorption syndrome and weight loss. Without treatment, some may be asymptomatic carriers for a long time.
Treatment. Metronidazole or thimidazole
Literature: Dunn N, 2022, Aikawa NE, 2011, Norwegian Institute of Public Health in Norway
Yellow Fever (yellow jack, yellow plague)
Africa and South America, virus, fever, chills, nausea, liver failure (icterus / jaundice), muscle pain, especially in the back. Vaccine is important preventively, but it is a "live vaccine" that cannot be used during treatment with immunosuppressive anti-rheumatic drugs
Definition. Yellow fever is a tropical disease caused by an acute viral infection. Rheumatic pain, mostly in the back, is part of the disease picture. People who have a weakened immune system, who when using immunosuppressive drugs against rheumatic disease cannot always use current vaccine.
Disease Cause: Flavivirus
Contamination. Transmitted most commonly via mosquito bites or ticks.
Occurrence. Central/South America + Africa (incl. Kenya). Not in Asia.
Incubation; 3-6 days.
Symptoms. Initial stage: Fever 40 degrees C and sweating, severe headache, muscle pain, especially in the back, conjunctivitis (eye inflammation), nausea and vomiting, relative bradycardia (slow pulse, despite fever). Remission (recovery) on the 3rd or 4th day with falling fever. The disease can still flare up with a new fever and risk of organ damage. Stage with liver damage (in 15%); hepatitis with icterus (jaundice) and vomiting, nephritis (kidney inflammation) with proteinuria, mucosal bleeding, epistaxis and gastrointestinal bleeding. Mortality in a toxic phase is approx. 20%.
Rheumatic symptoms. Muscle pain, especially in the back. Vaccine is important preventively, but it is a "live vaccine" that cannot be used during treatment with immunosuppressive anti-rheumatic drugs.
Diagnosis: Blood tests with a slightly low number of white blood cells and platelets, lympho/monocytosis. High liver enzymes, bilirubin, proteinuria Virus RNA in blood test with PCR Technology is the best method. IgM rise after a few days detectable.
Complications : Liver/kidney failure, meningo-encephalitis (brain inflammation). Multiorgan failure
Course: From mild flu-like course to fatal outcome.
Differential diagnosis: Hepatitis (liver inflammation), malaria, Rikettsia, Morbus Weil (Leptospirose), Dengue fever, Hemorrhagic fever, Marburg virus, Ebola Virus.
Treatment: Quarantine/isolation in mosquito-isolated rooms if suspected (6 day incubation period). One tries anti-viral treatment (for example with ribavirin).
Medical prognosis / life expectancy: Yellow fever in children before the age of 14 is rarely fatal. In adults up to 50% mortality. Leaves lifelong immunity.
Prevention: Alive vaccine (weakened viruses). Vaccine effect starts after 10 days. Immunosuppressed patients on high doses of cortisone, chemotherapy or Biological treatment should generally not have live vaccine. Since 1996, more than 13 serious complications have been reported, including 6 fatal vaccine complications.
Literature: Simon LV, 2022, Romano APM, 2014
Leishmaniasis (Kal-azar)
Tropical regions (Africa, Asia, South America), Mediterranean region, parasite, skin (chronic wounds): Weeks-months after infection.Wounds in the mouth and nose, fever, liver, spleen, anemia: Months-years after infection. Joint and muscle pain. Increased disease risk among people who use immunosuppressive drugs.
Definition. Tropical disease caused by the leishmania protozoa which belong to the parasite group flagellates and are spread via sandflies. Kala-Azar ("Black fever") corresponds to the visceral form. Joint and muscle pain can be part of the disease picture. People with a weakened immune system, such as when using immunosuppressive drugs for rheumatic disease, can get sick more easily.
Three main types:
- Visceral type (spleen, liver, anemia, fever) (Kala Azar)
- Cutaneous form (orient wound)
- Mucocutaneous form (mouth and mucous membranes)
Occurrence. Incidence in Norway: Leishmaniasis was notifiable in MSIS 1975-94. During this period, 4 cases of visceral leishmaniasis were reported to MSIS. The place of infection in all cases was Spain in persons of Norwegian origin.
Visceral leishmaniasis (Kala-Azar = black fever)
- Mediterranean countries, Middle East (including Turkey)
- China (Leishmania infantum)
- Indian subcontinent
- East Africa (L.donovani)
- South and Central America (L.chagasi)
- 90% of cases in the world occur in Bangladesh, Brazil, India, Nepal and Sudan
- Children are most affected in the Mediterranean, most adults are affected in India and Africa
- 500 new cases of visceral leishmaniasis annually
- Dogs and other animals are reservoirs in the Mediterranean countries
- People's only reservoir on the Indian subcontinent
- Mainly in South and Central America (L. brasiliensis)
- Mediterranean and Middle East (L.tropica and L.major)
- 90% of cases in the world occur in Afghanistan, Algeria, Brazil, Iran, Peru, Saudi Arabia, and Syria
- 1,5 million new cases of cutaneous leishmaniasis annually
Both forms of leishmaniasis may occur in Norway as imported cases.
Contamination. Increased risk of infection for people with a reduced immune system. Sand fly bites transmit infection. Sand flies found mainly in arid and semi-arid areas in villages, underground rodent tunnels, thickets and rock piles, in South America also in tropical forest. The flies have a short radius of action. Reservoirs for the parasite are humans and animals, and vectors are blood-sucking butterfly mosquitoes of the genera Phlebotomus and Lutzomyia, so-called sandflies. Wound material in the cutaneous type can in rare cases be transmitted from one person to another. The parasite can also be transmitted through the use of unclean syringes. The genus Phlebotomus occurs in Europe, Asia and Africa and Luzomyia in South America.
Incubation time (from infection to symptom). Skin: Cutaneous form: from 1 week to several months. Internal organs: Visceral form: from 2 – 6 months.
Symptoms and course.
Visceral form (mostly in the stomach and intestines): Systemic disease. Can have a serious course. Fever over weeks without response to steroids. Diarrhea and weight loss. Medical examination findings. Enlarged spleen and liver (hepatosplenomegaly), large lymph nodes, anemia and pancytopenia (low blood cell count as a sign of bone marrow infiltration). Dark pigmentation in the skin may occur in the palms of the hands or temples. High CRP, SR and IgG-
Cutaneous form (mostly skin). Development of red-brown nodules with central ulceration ("oriental ulcer") on the face, shoulders or upper arm. Punch biopsy for biopsy and PCR
Mucocutaneous form (mostly in mucous membranes and skin). Ulcers in the mucous membranes can over years erode the palate and nasal septum.
Rheumatic symptoms: Joint pain and muscle pain.
Diagnostics. PCR tests are routine. Detection of protozoa by direct microscopy of biopsy from wound edge, liver, bone marrow or lymph nodes. Serological test.
Treatment. Systemic, specific antibiotic treatment (antimony preparations, amphotericin B) against both forms of the disease.
Preventive measures. Covering the body to avoid stings. There is no vaccine. No special measures for imported cases. People who have or have had Kala-Azar (Visceral form) are permanently excluded from donating blood. Not required to report to Norwegian MSIS.
Literature: Maxfield L, 2022, Aronsen N, 2016 (American guidelines for diagnosis and treatment), Müller KE, 2021, Pagliano P, 2017, Maritime M, 2018, Blomberg B, 2019 (Patient Case Study in Norwegian).
Malaria
Africa, Asia, South and Central America. Parasite. Fever, headache, fatigue, vomiting.
Definition. The tropical disease is caused by a parasite. After Tuberculosis (Tbc), the world's most common infectious disease. 90% of cases are in Africa. Benign (benign) form (1/3 of cases). People with a weakened immune system, for example during treatment with immunosuppressive drugs for rheumatic disease, can have a more serious course of the disease. Rheumatic pain in the arms and legs is part of the disease picture.
Different types
Plasmodium quartana à Malaria quartana. Incubation period 21 – 42 days between infection and symptoms. Fever rhythm: 2 days without fever. The disease does not go away by itself.
Plasmodium vivax and Malaria tertiana: Incubation period 10 – 21 days between infection and symptoms. Fever rhythm 1 day without fever. Duration of illness: within a maximum of 5 years.
Plasmodium falciparum (Malaria tropica): Malignant (severe) form (2/3 of cases). Incubation period: 7 – 10 days (90%, 10% longer) between infection and symptoms. Fever: Irregular. Duration of illness: Up to 2 years if not fatal.
Symptoms. Fever with chills except M. Tropica which may have subfebrile temperatures. Fever up to 2 years after staying in the tropics. About. 90% make their debut in the first month after staying in the tropics. Headache, cough (differential diagnoses: Influenza, sepsis), pain in the right part of the upper stomach area. Icterus (jaundice) (differential diagnoses: Liver/biliary disease). Gastrointestinal: nausea, vomiting, diarrhea (differential diagnosis: Gastroenteritis). M. tropica (most severe, malignant form). Cerebral malaria (disturbance of consciousness, confused, coma) (Differential diagnoses: Psychosis, meningitis. Pulmonary edema, cardiac shock (differential diagnosis: heart disease, pneumonia). Acute renal failure (differential diagnosis: primary kidney disease).
Rheumatic symptoms: Pain in arms and legs.
Examinations; Medical history with typical disposition and symptoms (see above). Clinical examination shows hepatosplenomegaly (large liver and spleen) and in blood tests hemolytic anemia (LD is high, haptoglobin in blood is low), thrombocytopenia (low number of platelets), leukocytopenia (low number of white blood cells (differential diagnosis: blood disease). Hypoglycaemia (low sugar level in the blood).
Diagnosis. Microscopy of bBlood smear with Thick drop which is immediately microscoped at least 2 times a day on 2 consecutive days. Thick drop: 1 drop of capillary blood on slides using the corner of another slide is stirred in a circular motion ½ minute to a spot 1 cm in diameter. The thickness is such that you can read newspaper letters through the slide. After 30 min air drying: GIMSE dyeing, then again drying and microscopy (alternative rapid staining techniques). PCR Technology: result within 24 hours. Plasmodia antibody (result after 6-10 days).
Treatment. Suspicion of malaria infection (febrile patient who has been in the tropics in the last month before the onset of symptoms). Hospitalization: Immediate diagnosis and therapy. Uncomplicated M.tropica: Atovagquon + Proguanil (Malarone) or Mefloquin (Lariam), reserve agent: Artemether + Lumefantrine (Riamet). Complicated M. tropica: Quinine + Doxycycline.
Preventive: Absolutely safe prevention is not possible. Mosquito protection. Chemoprophylaxis with Atovaquone/Proguanil (Malerone) or Mefloquin (Lariam): backup agent: Doxycycline. Pregnancy: Chloroquine, but beware! resistance occurs.
Literature: Buck E, 2022, Laishram DD, 2012
Strongyloides stercoralis (Threadworm)
Asia, Africa, Central and South America, Australia, parasite in tropical regions. Skin (itchy eczema), lungs (cough and discomfort), bowel (slow or no bowel movement due to constipation/constipation), joint inflammation (arthritis) in the form of reactive arthritis is observed (reference: Mohanty S, 2017). Worldwide, at least 100 million people are infected. Among immunocompromised people, the infection can become serious. Literature: Carpio ALM, 2022.
Zika virus infection
Africa, Asia and Latin America (large outbreak in Brazil). Transmitted to humans most often via mosquito bites. Infection via sexual contact and via blood transfusion is possible. Increased risk of damage to the fetus (mikrocephali) if a pregnant woman becomes infected. Symptoms (ranging from no signs of illness to flu-like symptoms). Joint pain, muscle aches, fever, exhaustion, rash, eye inflammation (conjunctivitis).
Definition. Viral infection that is transmitted to humans via mosquito bites, mainly via Aedes Mosquito. Can presumably also be infected via sexual contact and via blood transfusion. It must be expected that people with a weakened immune system, as with immunosuppressive treatment for rheumatic diseases, may have a more serious course of the disease. Joint pain og muscle aches part of the disease picture.
Proliferation of Zika virus.
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Africa, Asia and Latin America (large outbreak in Brazil).
Symptoms; Fever, exhaustion, rash, eye inflammation (conjunctivitis).
Rheumatic symptoms. Joint pain, muscle aches
Pregnancy and Zika virus. There is an increased risk of fetal damage (mikrocephali) if a pregnant woman becomes infected, especially in the first 1/3 of the pregnancy. A study of 442 infected pregnant women showed that 6% gave birth to children with injuries after Zika virus infection (reference: Honein MA, 2017). Everyone with injured children was infected in the first three months of pregnancy. The risk of fetal harm is independent of whether the pregnant woman has symptoms of infection or is infected without noticing symptoms. Fetal injuries include brain damage, microcephaly (small head) and fetal death (reference: Brasil P, 2016).
Associated Zika syndrome can be defined by severe microcephaly, special brain malformations, changes in the eye (retina) Joint malformations (such as clubfoot), spasticity (reference: Hoen B, 2018).
Due to the 2016 epidemic, health authorities in several South American countries have asked women to postpone becoming pregnant until 2018 or later.
Literature; Wolford RW, 2021, Ploured AR, 2016 (Zicka virus), The Norwegian Public Health Institute Brasil P, 2016
